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Harm versus pain, an important distinction for physicians

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

13866052723_2020820f89_zAbove all, we medical students are told to do no harm. It’s a maxim that we follow religiously and is one of the pillars guiding the ethics of practicing medicine. But our professors don’t tell us what really constitutes harm because it’s not so easy to define.

The first time we touched a patient during a physical exam, we were timid with our hands and instruments, hyperaware of any twitches or jerks that could indicate pain. We made sure to attend to all the patient’s discomforts. Before we entered the room, we adjusted the collars of white coats to appear pleasing. We warmed our hands and dabbed the sweat off our palms. When we palpated his abdomen, we pressed ever so gently, barely making a crater in his stomach. Even when placing our stethoscopes on his chest, we would do so delicately because if we pressed too hard, it would leave a bruise — or so we feared. Reflexes often could not be evoked because we didn’t want to fracture his kneecap by tapping it too hard with our hammers.

When we practice medicine, we walk a tight rope between life and death that has no safety net.

It is easy to conflate the two, but pain is not synonymous with harm. And we must realize that important distinction to practice good medicine. After all, in order to prevent, treat, or even cure disease, we will invariably have to cause the patient some degree of pain, and the physical exam is no exception. We must press the abdomen with enough force to feel the edges of internal organs or shine a blinding light into the pupils. But these tasks cause only relative discomfort.

What about more invasive procedures?

Mammograms can be painful and emotionally draining. Colonoscopies are uncomfortable and awkward. Prostate exams and pap smears force the patient into an undignified and vulnerable position. Even the quickest blood draw can tap into incapacitating needle phobias. And chemotherapy, the epitome of doing good by causing suffering, intends to trade months of agony for potentially years of survival.

So do we give a free pass to those patients who don’t want to undergo these procedures and whom we don’t want to see suffer? The greatest fear of any practitioner is to accidentally hurt the patient, and naturally, we are tempted to the easy route of inaction to avoid this possibility. Ironically, this deep-seated fear that can make us competent and caring physicians can also inhibit us from doing our duty.

Twice a week in class, we perform dissections on cadavers. It’s a practice in the exploration of the human body, and at times, it’s ugly and chaotic. To expose underlying structures, tendons and ligaments are cut. Bone is sawed apart. Fat is shredded away. Skin is peeled off. And inevitably amidst this messy process, a clinically important nerve or vessel — one that needed to be preserved for us to study — would be severed. Luckily, our ineptitude didn’t lead to any injury and we could always later on rely models to view the structure that we mishandled.

But when we practice medicine, we walk a tight rope between life and death that has no safety net. A missed finding on imaging may mean a lost opportunity to catch an early cancer. A nicked artery during surgery can cause an increased likelihood of stroke later in life. A shoddy patient interview could lead to giving drugs that could cause a potentially fatal allergic reaction. Treating even the simplest of patient cases is akin to walking through a minefield where we’re more likely to take the wrong step than the right one.

Yet we can't let this paranoia dictate our care because what is ostensibly comforting and safe in our opinion may ultimately prove harmful for the patient. It’s possible for us to overcome this fear by distinguishing the muddled line between harm and pain, which could require years of nuance and experience. So until then, perhaps the new maxim that medical students should take to heart is simply, above all, heal the patient.

Steven Zhang is a second-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail. 

Photo by COM SALUD

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